Dissertation Presentation Thomas Cox RN Doctoral Candidate Virginia Commonwealth University School...

Dissertation Presentation

Thomas Cox RNDoctoral Candidate

Virginia Commonwealth University

School of NursingApril 7, 2004

http://www.standarderrors.org/

Copyright 2004 Thomas Cox

Who Am I and What Did I Do?

NurseSocial Worker

Mathematician/Statistician

Dissertation research: “Risk Induced Professional Caregiver Despair: A Unitary Appreciative Inquiry” – Unitary Appreciative Inquiry with eight RNs into the impact of capitation contracts, managed care, DRGs on registered nurses working in acute care hospitals in the Mid-Atlantic area.


What Will I Cover Today?

Background and Research Themes

Professional Caregiver Insurance Risk

Study Design, Recruitment, & Interviews

General Findings

Nursing Surplus (NS)

Implications

Questions - Answers

Future Directions


My Background

Nursing

Social Work

Health and Social Services Planning

Statistics/Biostatistics

Program Evaluation

Education

Actuarial Science and Risk Theory


Persistent ThemesClients’ rights to receive mandated services

Who are clients?State hospital patientsNursing clientsStudents

Ability of caregivers to give high quality care

Who are professional caregivers?NursesMDsSocial workersTeachers…


The Rights of Clients to Receive ServicesTHE BEGINNINGS

Experiences

Suffolk County Dept of Social Services and VISTA

Providing services to clients

Quasi-legal advocacy for clients

Reflection, Conceptualization and Theory Generation:Cox, TH (1976). Denial of services in public agencies: A white collar crime. Proceedings of the Sixth Annual Sociological Research Symposium of the Alpha Kappa Delta Sociological Honor Society (Eds. Hickey PD, Nelson LD, Schwartzbaum AM, Westerberg NR & Williams JS) pp 401-8, Virginia Commonwealth University, Richmond, VA.Copyright 2004 Thomas Cox

The Rights of Clients to Receive ServicesExperiences

CSH & VCUHS

Sharing experiences with numerous RNs, Admins, AHPs

Dissertation research

Reflection, Conceptualization and Theory Generation:Cox, T. September 2002: Professional caregiver insurance risk and average cost based reimbursement plans: Implications for nursing. Advancing Nursing Practice Excellence: State of the Science, Washington, D.C.

Cox, T. April, 2004: Risk induced professional caregiver despair: A unitary appreciative inquiry.


If Nightingale were here now…

Would Nightingale think that “profit sharing”, “risk sharing”, “capitation contracts”, and “DRGs” were good ways to fund nursing services and manage hospitals and health care services?


If Nightingale were here now…

Would Nightingale think that “profit sharing”, “risk sharing”, “capitation contracts”, and “DRGs” were good ways to fund nursing services and manage hospitals and health care services?

I don’t think so…


Why are?There so many HCO consolidationsCalifornia MDs retreating from CCsPts feeling abandonedRNs working mandatory OTThere fewer supplies on unitsPt care standards different w/in same hospitalHCOs profitable when RNs think care is poorSo many temp staff on nursing unitsSo many people uninsured/uninsurableThere shortages of RNs & satisfying RN roles

RNs crying/despairing


Professional Caregiver Insurance Risk

Myth: Carving up aggregated insurance policies and redistributing them to health providers will adequately fund health services

Perpetual Motion Machines Require “No Friction”

What are insurance risk transfers: CCs, DRGs, HMOs, MCOs

Insurance risk transfers also occur in budgeted nursing units

PCIR transfers turn MDs & RNs into insurance claims personnel

At average levels of funding – half of patient’s needs will not be met

Insurance analogy new insights into nursing management

We must address and deal with PCIR because nurses do


How Insurance Transfers Reduce Resources

The Normal CurveCentral Limit Theorem and the Law of Large Numbers

Inverse relationship of sampling theory – the smaller the collection of insureds the less precise the estimated costs

If insurer distributes insureds to 20 providers – they each have much higher probability of high losses or profits

To protect themselves from loss – providers must target service costs below those assumed in insurer’s premiums

The situation gets worse when we get down to 20-30 clients on the nursing unit or 2 – 8 clients for one RN


Comparison of VariabilityLarge Sample v Small Sample

-15 -10 -5 0 5 10 15

0

0 .0 5

0 .1

0 .1 5

0 .2

0 .2 5

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0 .3 5

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0 .4 5

Variability Comparison - Small v Large Sample

Large

Small

Large Sample SD

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Comparison of VariabilityCaregiver v Insurer

-15 -10 -5 0 5 10 15

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0 .0 5

0 .1

0 .1 5

0 .2

0 .2 5

0 .3

0 .3 5

0 .4

0 .4 5

Variability Comparison - Insurer v Caregiver

Insurer

Caregiver

Insurers SD

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Table 1Risk and Relative Risk of Losses on Portfolios for Health Care Providers versusInsurers When 5% of the Insurer Portfolio is Transferred to a Health Care Provider

0.85 0.5000 0.5000 1.00000.87 0.3446 0.4644 1.34800.89 0.2119 0.4290 2.02500.91 0.1151 0.3942 3.42600.93 0.0548 0.3603 6.57400.95 0.0228 0.3274 14.38900.97 0.0082 0.2958 36.07800.99 0.0026 0.2656 103.95501.00 0.0013 0.2512 186.0540

Assumptions:

Loss ratios distributed as N(0.85, 0.05)

5% of Insurer portfolio is randomly distributed to provider

Insurer Loss for Full Portfolio

Insurer Risk of Greater Loss:

Provider Risk of Greater Loss:

Relative Risk of Provider Loss v. Insurer Loss

Table 1Risk and Relative Risk of Losses on Portfolios for Health Care Providers versusInsurers When 5% of the Insurer Portfolio is Transferred to a Health Care Provider

0.85 0.5000 0.5000 1.00001.00 0.0013 0.2512 186.0540

Assumptions:

Loss ratios distributed as N(0.85, 0.05)

5% of Insurer portfolio is randomly distributed to provider

Insurer Loss for Full Portfolio

Insurer Risk of Greater Loss:

Provider Risk of Greater Loss:

Relative Risk of Provider Loss v. Insurer Loss

Specific Research Objectives

Understanding the lives of professional caregivers experiencing risk induced professional caregiver despair through their individual and collective voices;

Discovering experiences, perceptions, and expressions of professional caregivers about possible strategies they believe would generally improve their professional lives.


MethodUnitary appreciative inquiry – Cowling

Praxis method within Rogers’s science of unitary human beings

Action Research

Collaborative, cooperative, appreciative inquiry (Cooperrider & Srivastva and Heron & Reason)

Research ‘with’ participants rather than ‘on’ participants

Interview participants & collaborate to develop appreciative profiles

Appreciative profiles are narrative interpretations of the experiences perceptions, and expressions of participants

Four specific forms of knowledge: experiential, presentational, propositional, and practical


Recruitment & Description of Participants

15 inquiries and 8 RN participants employed at acute care hospitals in the Mid-Atlantic area

Self-describe as experiencing risk-induced professional caregiver despair

Flyers, word of mouth, referrals from participants and colleagues, website, LSs, presentations

Meet 1+ times

Interview lengths of 25 mins – 3+ hours + phone calls & email exchanges to clarify experiences and work on appreciative profiles

7 Females - 1 Male RN

OR, Psych, Transplant/Oncology, Maternity/Peds, Med-Surg, Agency RN

Time employed in Nursing: 1+ - 22 yrs; Ave Age:45 (Range 37-51)Copyright 2004 Thomas Cox

Findings


Carol

20+ years experience in OR settings

Married with two children

Shared information quite unexpected by the researcher

Revealed that resource shortages, poor staffing, and deficient equipment and supplies affected employees and clients alike

New, multi-facility contract for acquisition of supplies from a company several hours distant was having a negative effect on the quality and availability of supplies contributed heavily to this researcher’s development of the theory of professional caregiver insurance risk and nursing surplus

Inadequate surgical equipment and supplies and non-functional protective drapes


DeborahEntered nursing in her 30s - Oncology nurse, married, FNP student

Increasingly concerned about declining standards of care, reduced #s of oncology certified nurses at work, use of non-oncology trained nurses, and rise of an overly punitive employment environment

Candide: satire by Voltaire (1960/1759). Dr. Pangloss suggests that the world is the best it can be despite the horrible experiences of Candide that suggest otherwise. She feels that people around her, particularly administrators act as though the standard of nursing care is the best it could be

This philosophy prevails in her nursing unit despite the fact that supplies are scarce, equipment is misused or unavailable, staffing is inadequate, nurse’s legitimate concerns are ignored, clients and nurses safety is compromised in favor of cutting costs, and that the care of her clients is routinely compromised

Recycled pillows and patient mix issues Copyright 2004 Thomas Cox

Gloria

Associate degree oncology and transplant nurse

RN for more than ten years

One of the most compelling stories related by any participant, and among the most vivid and memorable experiences of the researcher

Contributed important understandings about inadequate supplies and staffing, and declining care

Profoundly influenced the researcher’s work on professional caregiver insurance risk and risk induced professional caregiver despair

Inadequate supply schedules, failures in central pool staffing, impact of temp and agency personnel…

Most important contribution – disparities between staffing, supply, and administrative support between different units in the same organization


Findings – Cross-Case Themes

Scarcity of material resources and equipment; Staffing quality and quantity – float, temp, agency; Compromised client care and physical plant environmental quality; Relationships with and support from other units in the hospital; Mixed populations of clients;Support from and responsiveness of nursing managers and nursing execs;Workflow and documentation concerns;Dealing with insurance companies and the claims management role;Financial information at the bedside and PCIR;Use of national or regional data as benchmarks for individual hospitals;Documentation and monitoring the status of nursing surplus;Client advocacy in the PCIR environment;Pre-qualification and the nursing ethics of differential care


Impaired Insurers and Nursing UnitsInsurers stay viable when they have redundant resources & other regulations limit them from operating with inadequate resources

But insurers do go bankrupt…

How are experiences nurses face like insurers headed to insolvency?

Increased acuity on units (Lax underwriting standards)

Decreased staffing/resources (Inadequate Surplus)

Greater mix of clients (Inappropriate class plans)

Reduced length of stay (Short-term, high-risk policies)

Inadequate assessment of needs (Understated reserves)

Loss of experienced staff (Solid assets Junk bonds)

Temporary staff (Volatile assets)


Questions - Answers


Nursing Surplus IssuesInsurance companies monitor and report solvency continuously

(Current liquid assets – Estimated liabilities) > 0

Because risk transfers to health providers reduce money available for services – health providers become cost-conscious - interfering with quality, efficiency, nursing surplus & nursing ethics/values:

Local medical supply service Distant supply facilitiesWell-maintained unit supplies Central storage

Regular staffing schedules q 4-hour, transient workersTime to maintain unit Inadequate time to meet basic needsOperating critical service Product line/Manufacturing opsRNs indifferent to cost RNs balance financial/clinical ethicsPublic health capability Inadequate emergency resources

RNs able to plan shift activities q 4 shifting changes patients


Nursing Surplus AdequacyHow often should a nursing unit be able to meet greater than average demand?

25%, 50%, 75%, 90%, 95%…?

Nurses need redundant: supplies, equipment, medical, professional & housekeeping staff to meet unexpected demands – the usual

Evaluate NS for each shift and unit – not the organization:Mix of staff and patientsEquipment and supplies on the unitFit of patients assigned to staff/unitSpecific skills and abilities of RNsRN status – overtime, end of week, start of weekAbility of organization to shift resources on demand

Is each shift/unit adequately resourced or only ‘on average’?


Nursing Surplus InadequacyRNs reported inadequate resources, q 4-hour staffing, inappropriate clients, unfamiliar staff, & dangerous conditions

Nursing surplus diminished when resources are inadequate, personnel are not familiar with patients’ needs, equipment, policies & resources, and RNs cannot count on supplies or co-workers

Organizations increase Nursing surplus when:

RNs’ needs are the optimization focusPatients are assigned to RNs able to care for themServices & resources are seamlessly availablePolicies/procedures are rational, efficient & realisticManagers & executives manage variability

Insurers cannot sustain operations without surplus and nursing units cannot deliver quality care with inadequate nursing surplus

Thinking of nursing units ‘as’ insurers highlights vulnerabilitiesCopyright 2004 Thomas Cox

NNN, MIS and NS

Assess nursing surplus: What was done, needs to be done, what resources are available/missing, how to fix it…

NNN/MIS - What RNs did/should have done, what the result was – how nursing surplus was used and will be used

NNN/MIS – forecast what should happen next – assess staffing and resources in real time – are resources adequate now – if not – fix it!

NNN, Nursing surplus & MIS tie what was & what needs to be with the ability of RNs & units to meet the routine AND unexpected

Accountability/visibility: Expose care impediments due to persistent, hidden, and correctable situations

NNN, MIS & nursing surplus may reduce the burden on managers and executives to take unpopular stands – data speaks for itself

Nursing surplus is an ‘objective’ statement of capacity to ‘care’Copyright 2004 Thomas Cox

The Future IDevelop MIS designed for RN’s needs – monitoring, maintaining, and building nursing surplus

Support RNs management of clinical & insurance risks - timely & accurate analyses assessing past, present & future nursing surplus

MIS design determines the character, utility, quality, quantity, & availability of critical nursing surplus management data

New tools for projecting costs and demands RNs need to win budget skirmishes and avoid standing alone

How to incorporate national data in projecting local experience?

New training needs for RNs in rapidly changing environments?

How well do RNs and health care organizations fulfil their insurance claims functions?How well do RNs balance the conflicting demands of the dual role?Copyright 2004 Thomas Cox

The Future IIImpact of PCIR on:

People of race/colorGenderPeople with disabilitiesSevere and persistent mental illnessChronic v acute illnessRural v Urban settingsInsurance mechanisms and insurabilityElderly populationsCommunity v hospital careFunding of nursing services, nursing, and nurses


The Future IIINursing practice models – opportunities and hazards:

Clinical Nurse Leaders

Will nurses take the opportunity to create lower cost, higher quality alternatives to the current health care system?

What skills will they need?What opportunities will exist?How will they alter nursing practice?How will they manage nursing services more effectively?


Sobering ThoughtsWhen RNs, NPs, and MDs function in dual roles as clinical decision makers and insurance claims agents it eventually comes down to a health care professional addressing these questions:

For the client I am serving right now, will I put my job on the line as an advocate for more and higher quality care if my employer may bear the costs?

Can I separate out the right of this client to receive service and recognize that some clients require far greater care than average and that my treatment of this client will affect my treatment of my next client?

The strength of insurance claims management is that insurance claims personnel have no conflicted loyalties, do not know the client, and are handling many claims every day – not true when health care providers enter the insurance business. Copyright 2004 Thomas Cox

http://www.standarderrors.org/


Dissertation Presentation Thomas Cox RN Doctoral Candidate Virginia Commonwealth University School...

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